Category → Operations
I need to Get This off my Chest ……..
This post is fat too long which is why I never published it. Please try and read it …….. pretty please ….. all 6 of you who still visit this site.
You’re first day in medical school: 3 subjects for 1 year, biology, physics and chemistry, mostly rodents, reptiles and Schiff bases ……. stuff I can’t remember anymore ……. nor will I ever need ………
Your second and third year in medical school: You’re finally seeing a human body for the first time, you see the parts (anatomy), the mechanisms (physiology) and the witchcraft (biochemistry).
You’re fourth and fifth year: you go through diseases through pathology and microbiology but barely see 20 patients a year …… half the time you don’t know what they are doing or what you’re doing to them just taking a history (interview) and physical exam ………. forget the diagnosis …. that’s miles off.
The final year: you read and read and read and read …… then realise that you’ve barely seen enough to know how to recognise what you’re reading if a patient even had it.
Graduation day: You’re happy! YOU ARE DONE! but what now? where do you go from here? you’ve passed, you know your stuff ………. but don’t know what to do next …….The reasons why you went to medical school in your first year are forgotten and you’re not all that inspired, you want to treat people …. but that’s it …… you don’t even know how to prescribe yet …….
That’s a summary of my medical “education” and as most of you can tell, I’m not exactly satisfied by it. Now, I’m not an educator, I’m no teacher. They need to inspire, to have that ability to make you trust them enough to guide you; they have to have that gift that lets them build a mental structure in which information can be stored and eventually made useful. Sadly, few of mine did and looking around at the new batch of interns from both Kuwait and abroad few of them seem inspired. Don’t get me wrong, they work hard, right to the bone, they have skills but not the useful ones.
How many of the young doctors you see/meet actually make you feel comfortable, know how to ask the right question at the right time, know how to tell someone they have cancer or that a persons father died minutes ago?
How many of the doctors reading this (if any …… ) actually feel a sense of awe at what they do? how many of us actually enjoy reading about how IV fluids (drip …. or drib) were originally made? Or how the inhalers (Ventolin) we use evoloved? or why we tend to wear green or blue or green scrubs rather then white or grey ones? Or who the first open heart surgeon was and what he did to get there? How many of us were taught the ethics behind palliative care? Contraception? and experimental treatments? or how clinical trails evolved and the difference between that and standard treatments?
Medical history isn’t the reason why you go into medical school, it isn’t how you save lives, but in that third year when all you know is the Krebs cycle (the gearbox of your metabolism) and the anatomy of the Brachial plexus (nerves in your arms) you need to feel inspired by people who’ve done it before you. You need to find a reason to read, to debate, to analyse and to understand and during that final year, you need to learn why trying out new treatments for MS and charging people for it is unethical and why the current mudeer is a douche and why patients blame you for cancer rather than try to understand it…….
You don’t learn these things in textbooks on surgery, rheumatology or internal medicine, and contrary to popular belief you won’t learn them by parading the hallways in your new white coat and seeing 50 patients in the emergency room ….. you learn them by reading the ethics, the sociology and other humanities that underpin our profession.
Kuwait University and others like it have the ability to reshape education and inspire us. The reason why they can is because unlike other institutions it was built from the ground up to educate us, other institutions need to attract research grants to survive,we don’t.
We also have experienced faculty, there are people currently teaching who were there when stomach stapling came to Kuwait and can tell us how they tackled it, who they dealt with mistakes made during that first cases, the second one and the third. We have people who saw Viagra become the drug du jour and who saw the eradication and rebirth or tuberculosis in Kuwait.
We need to reshape our education and have graduates who can debate, discuss and be knowledgeable in our field without feeling that reading ethics 1 day a week is a waste of time.
Maybe then we’ll stop hearing about how doctors who “don’t know my name’, “don’t spend enough time with me” or are “too brash” or “shyif nafsa” and maybe then doctors won’t get slapped around so much.
I’ll leave you with the quote that he read to me one afternoon years ago and introduced me to the sense of awe , the need to read on medical finance, history and ethics; humanities presumed dead by our colleagues and up and comers (yes, student ……. you’re not my colleague yet …..). It was by John Cardinal Newman who described a university as a citadel built with the purpose of:
‘raising the intellectual tone of society, at cultivating the public mind, at purifying the national taste, at supplying true principals to popular aspirations, at giving enlargement and sobriety to the ideas of the age, at facilitating the exercise of political powers, and refining the intercourse of private life.’
I only hope that I can one day see this in our local University who’s faculty and students should expect more from each other …….
…. Just go Buy a Car …..
Following on from last weeks post the next think I’d like to talk about a minority we have in Kuwait ….. the pedestrian …… usually of bengali ethnicity, often with a lack of linguistic skills or clothing, lets face it the rest of the damn nation have a fear of using their legs to cross the road and with good reason …… who would want to sweat in the 150kd track suit ……..
Thanks to their inability to wait till the road clears and our inability to account for a fast moving dark figure in front of us at 2 am. Bengali’s and street cleaners account for possible 70% of all pedestrian car injuries and while most of this injuries tend to look minor (either a broken foot or arm and a bleeding cut wound) a fair number will have a secondary injury that we can’t really detect unless we’re more thorough when we examine them. (and by we I mean people in the medical community, usually a trainee or an assistant will be first on the scene, so this post is mainly for the people who read this, this and this as well as the people who write in them.
Pedestrians are funny creatures, specially bengali ones because when they are hit they tend to flail around and smack them selves on the hood and the bumper leading to more injuries. They also tend to have a very low threshold for pain and rarely if ever know how to speak Arabic (and you can forget about English) so nine times out of ten what you get in the casualty is a person who was hit by a bumper, slammed himself onto the windshield, broke the glass against his face and flailed around rubbing the shards of glass in subsequently falling to the ground and possibly being left there for about an hour or two before being brought into hospital and if you’re fortunate enough to have received the patient right after the accident then your are just as likely to receive your fellow country man or woman who has just hit him and will probably complain about how he needs as many x rays, pills and drips as the bengali does and will take up most of your time simply because he or she wont stop shouting at you or the nursing staff.
What’s interesting is that if you go purely by numbers (which is what the european health and safety network did) most of the pimary or secondary injuries you will see will occur either in the head or the legs. and of those most will be occult facial fractures that won’t swell up for a day or two. Very few will have actual brain injuries ’cause you skull can literally take a good kick from a premier legue footballer (about 9 Kilonewtons) and still not crack where as a baseball thrown in the right direction (0.8 Kilo newtons) will burst your cheek bone open and the same goes for your legs you’re more likely to hurt a joint than a bone and are more likely to hurt a nerve than a joint but how many of you woh have been through a car accident have actually been examined for knee joint injury or numbness? Very few doctors do it ……
Another thing that people tend to forget is that a pedestrian is 3 times more likely to hurt is chest than his abdomen and yet if you ask most general surgeons (you won’t see a trauma surgeon ANYWHERE in kuwait, all of them work as general surgeons for lack of a formal department or training) they’d be more concerned if you told them you didn’t order an abdominal ultrasound than if you didn’t order a chest x ray, they’d still want you to order it but will probably rubbish it off.
It’s things like ignoring facial fractures and loose teeth, not looking for joint damage and looking for fractures instead and ignoring rib fractures that lead to the horror stories like the guy who was in a car accident got his ankle fixed and never got his chest checked out. Three months later he was still in pain turns out he had a rib fracture, the reality is that ribs heal themselves for the most part but still ….. I’d like to know if I cracked a few …..
So the take home message here is that pedestrian car crashes which look minor usually are and do not required active resuscitation or ABCDE’s as was mentioned last week. But that doesn’t mean that they should be neglected. Pedestrians differ from major trauma’s in that they are more likely to have joint and tendon damage than to have fractures and are more likely to have facial fractures than skull ones. Another thing to bear in mind is that patients who have been hit by a bumper in their torso and are more likely to have rib fractures than abdominal bleeds, however if they are unstable then chances are your problem is in the abdomen oh and never forget there are 2 different types of injury to look out for, primary (car Vs. Human and secondary Human Vs the thing he fell onto after the car hit him/her)
All this information and more is available here in a report written by Dr Jikuang Yang of Chalmers University, Gotenburg-Sweden.
Boom Boom Pow
This post is based on a white paper I wrote some years back and is an attempt at talking about something a wee bit more serious, far too long and far less entertaining that titties, hoo hoos and mens naughty bits.
Despite public opinion we’re not half bad at managing a good serious car crash with multiple injuries, we’re infact pretty good at it statistically speaking. We tend to do pretty well in those because we apply a basic set of principles to them and tend to analyze them in a systematic fashion starting with the patients throat (airway), breathing and blood flow/loss (circulation) moving on to their neurological status and any evident disabilities and ending with the extremities(arms and legs) and external injuries. The so called ABCDE of trauma.
Our problem lies in minor or moderate traumas; trauma like a boy slamming his head against the front seat, or a fat person who’s seat belt was worn wrong and broke some ribs. If your patients breathing, talking and screaming then chances are that the ABCDE’s go out the window and you end up doing a couple of x-rays, routine bloods and observation, maybe a written police note to prove that it was a car accident and it’s for this reason that horror stories occur and don’t tell me you’ve never sent a patient home until you’ve checked everything because if you do you are either a liar or have not seen a patient in the past 15 years.You never hear stories about the guy who came in unconscious and was treated, you hear them about the guy who came in with a cut in the forehead, had it stitched and went home, to bed and never woke up (yes, I know it’s called a lucid interval)
So ultimately what I’m trying to say is that we can never be too careful when dealing with trauma patients and victims of car crashes. And where does the solution lie? In a zero percent doctrine that would put more strain on the system and end up in people having to get cat scans from head to toe and being subjected to enough radiation to kill spider man? In a centralised trauma center in which no doctor will want to work because they aren’t paid enough? or in hiring in trauma people from abroad who have never seen a car embedded on a lamp post after travelling at 180 Km/h in an effort to catch a glimpse at that sweet young thing with tha purty eyez ……
I sincerely doubt that any of the above will save lives. Having spent an admittedly short amount of time observing how minor traumas are managed and how accidents occur in this country here’s what has come to light:
1) We need to apply some thinking when patients come in through the door. similar to the ABCDE’s mentioned above but with a little more logic added maybe
2)Preventing traumas is cheaper than fixing the corned beef hash that comes in as a result of one.
However, there is a solution to our little problem that seems to be killing and maiming people in this country in a far worse manner than AIDS, cancer or the swineflu and it lies in looking to the past and recognising the work of one of the first real public health promoters in history; Dr William Haddon and medical doctor who was also a road safety engineer and his ingenious haddon matrix in 1970.It’s based on four different factors (the victim, the car, the environment and the social awareness within the area) over three different periods of time (pre-event, while in the crash and just after it) and it doesn’t take a health guru or ballisitcs professor or an expert hailing from Germany to come up with a worth while plan based on it.
The Victims:
Looking at the victim/passenger/patient the first thing that comes to mind is actually making them sit an exam and pass it rather than getting their cousin/uncle/father to help them pass it, most of us tend to need a little help when passing the driving exam in Kuwait and that is not a good thing, another thing is that most of us think that wearing sunglasses at sundown is a requirement when driving, this while increasing your sex appeal also tends to make you blind and make it more likely that you’ll crash. Making people use cumbersome fiddly hands free devices may sound like a good idea but in actual fact it’s probably more distracting than just picking up the phone and saying that you’ll call them later. Other good ideas include a mandatory seat belt and child safe seat in the back (i.e. the minute your kid is born the ministry should make it a requirement that you buy one or better yet receive one from them, it’s relatively cheap and makes sense).
The Cars:
In terms of vehicular factors we’re actually doing pretty well, most modern cars (thanks to our addiction to BMW’s and Mercs and Porsche’s) come fitted with anti-lock brakes, airbags, side airbags, seatbelts and flame retarded petrol tanks and piping as well as over-rev limiting mechanisms and collapsible dashboards; we do however have problems with bad lights, poor passenger numbers (12 people crammed into a toyota-taxi circa 1986) and lack of any regular mandatory inspections or part changes (don’t say you go to every service, most cars aren’t even fitted with the right tires or the right disc brakes for our weather and we bearly change them often enough, most people wait until the car stops or the world ends before they actually try and change anything). It’s funny how many people get stopped for the odd Chelsea sticker or window tint and how few are stopped because their rear lights aren’t working or because they honk the horn so much they end up distracting other drivers.
The Playground:
We also need a way on analysing the events such as CCTV on the highways and ring roads that show us how the crash happened and where the traffic is and perhaps even allow for ambulances to see the crash before it’s called in and while we’re on the subject our roads are just too damn curvy with twists and turns that make you feel like you’re in a ride at Disney world.
And how many of you actually rely on road signs, they are too damn small to read and even when you get close enough to read them they are often confusing (we’ve all missed that wretched turn into avenues as a result of a plaque the size of an A4 piece of paper!), Our roads also need to be designed with reserved ambulance routes, locked if need be …. you can use RFID tags on the damn ambulances to open them so don’t tell me there’s no way it would work! We use fucking magnetic tags to get into parking lots ….. use the same thing to block up a special lane…….
Society Vs. The Speed Junkies:
But by far the biggest and most daunting task ahead of us will be social awareness, not because or restraints such as money or organisation, but because we’re going about it the wrong way. SPEED CAMERAS DONT STOP PEOPLE FROM SPEEDING! Our bright young people love their fast cars and mating rituals and can afford to pay speeding tickets. The best way of preventing speeding is to provide a safe environment for it …… and yes, I mean a race track. Lets face it most people would love the idea of having a track day every week or an event such as Gulfrun or the like every two or three months (if it worked it Bahrain, it’ll work here ……)
Another thing we could do is provide basic life support (CPR, etc) training to laymen and laywomen, making it mandatory for everyone will never work but making it more accessible (i.e. annually at the work place or during their last year of high school….. if they can play Nintendo wii they can call 777 and give CPR) and giving people stickers and certificates that say that they are qualified will definitely get people coming in droves (lets face it people love sticking things on their cars (Fake M’s on their BMW’s and other things) and getting to say that they are qualified in “Basic Crash Management” or something to that affect will definitely seem attractive to at least 4 in every 10 of our lemming like youth.
So there you have it, it might not be the best plan in the world but it certainly beats two faced speed cameras, pictures of dead people and a mandatory FBI-esque earpiece on every driver.
If you actually read through this and enjoyed it please let it be known as I am/was planning a second post on how to systematically treat crash victims with minor/mild injuries.
Roxannne …… Put on the Red Light…….*
I wasn’t going to post this originally and expect a rather negative response ….. for the most part many of you will think I’m being sexist, making fun of women or mean to degrade them …… this is largely untrue …. I’m only shedding some light on a topic rarely discussed and have the utmost respect for most people regardless of their gender …..
Some days most days I wish I was him …..
Hookers, whores and call girls ……. perhaps I can sympathize with them because my calling involves largely the same hardships; we both work odd hours, are subjected to a fucked up system with rude and crude clientele or patients and rarely (if ever) get any thanks for it. Infact for the most part both medical staff and prostitutes get named and shamed in the papers regularly despite the best efforts of many working in their respective indutry(ies).
Like working for the Ministry of Health, prostitution subjects workers to violent people, those who are lurid and ofcourse the scorn of society for what is viewed as wrong, perverse, arrogant and generally rancid task that ought to be banned or at least regulated. And prostitution holds the same false stereotypes as healthcare does in terms of economic yield as everyone assumes that you’re making a boat load of cash …….. No I don’t drive round in a Bentley ……. and yes my daddy promised me I’d be rolling in it once I got through medical school ………. It’s been a while and the money still hasn’t started rolling in ……
Despite what most people think and the moral views held by our society prostitution is infact on the rise and although I have absolutely no data to support this a trip to your local casualty coupled with a 3 day trip to any given Dubai/Bahraini hotel would argue in my favor far better than any statistics ever could (and before you ask I’ve yet to pay for sex …… although it’s been a while ……. maybe I should book that room at the Grosvenor …… oh wait my salary means I can’t afford it ….. damn ….. wish I taught English lit. ….. at least I’d enjoy teaching kids Bukowski and getting slammed by the Students Union for it ….. ).
Ofcourse our fair ladies of the night are thought to be disease ridden, filthy, slime cunted and addicted to heroin. THIS IS GARBAGE; the industry is pretty darn healthy as the CDC (American Centre Center for Disease Control) recently revealed that the prevalence of HIV in the industry is far less than that of the general population (another stereotype put to rest); this ofcourse is based on a very limited study and does not take into account prostitution as a result of human trafficking and other illegal and largely inhumane activities which should be banned for the sake of both our industries …….yes, I do have a heart and a moral imperitive; though I rarely choose to act upon it ………
I’ve also always found it interesting how clients relate to prostitution and how they feel about it; most people I’ve talked to seem to mirror what most studies have concluded. They say that it’s because it’s easier, less complicated and you get exactly what you want from the relationship namely some fun, drinking and dancing and none of the drama everyone is afraid of essentially none of the maintenance and all of the benefits of a fun ride (no pun intended). I’ve personally always loved the drama that comes with a relationship; the fights, the making up, the going out to restaurants that nobody else goes to for fear of seeing someone you know …… fucking brilliant …. especially the fights ….. I could never keep a straight face and would end up laughing through the whole thing ….. explains why the longest relationship I’ve had lasted 2 weeks ….. I digress ….. apologies ….
I also think that there’s also a need for female contact that many people in our society lack, this makes social development skewed and by and large leads to a person going for a paid discreet type of thing rather than an awkward courtship which most people won’t approve of in the first place. Then there’s also the simple excuse for going to a hooker ….. “she’s fuckin’ hot and I’m fucking horny” …….. This is especially true of my married bretheren who seem to think that they have to cheat on thier wives as a requirement after a certain age …… fucking idiots don’t know when they have a good thing going ….
But then again some reports seem to say that most prostitutes tend to hate their job, want to kill themselves and have suffered some form of childhood trauma. I suppose that’s another thing that it has with medicine, we all hear about the good doctors who honestly enjoy their work and those of us who are abused by it and just want to die or kill the bastards who come in sick everyday …..
At the end of the day I doubt that anybody would be happy about or enjoy the idea of prostitution being on the rise but unless and until we become more mature in the way we handle relationships with the opposite sex its just one more thing we all know exists but never talk about (making it one of many industries that’ll never have health and safety standards, moral ones or any form of sanctioned regulation ……)
And anyone who thinks that prostitutes deserve to get raped, beaten and drugged up should just have a conversation with one of them at their local casualty …….. you can’t help but salute our working women for the shit they have to put up with day in and day out ….. from the law, society and the four year old adults they serve day in and day out.
*Yes, sting is infact the shit ……
I wanna do that to yer Face !
Click on the title to view the video …. fucking hilarious …..
One More Reason to Chug a Bottle of Cough Syrup …..
This post is far too short …. apologies …. ti’s a replacement for a really long Xmas post that was just too filthy …. even for by own lowly standards ….
Cough syrup actually taught me how to drink ….. as a young sickly lad you’d take a gulp of something that feels like it’s burning your tongue then you feel slightly better 20 minutes later …. if that isn’t a prelim to get you hooked on drinking I don’t know what is…. damn drug companies were prolly in cahoots with pub owners back then ……
But besides that cough syrup is good for other things, like getting off crystal meth (thanks, to the codeine* most brands contain …….. except those in Kuwait….. it’s banned here…. well not banned but not publicly available either …..) and getting high (you’d have to chug the whole bottle but it works ……. or so I hear ……. pretty good buzz too) and recently we’ve found out that the stuff is also good for curing cancer ….. well at least a couple of them …….
Dr Isreal Barken’s been using Noscapine (a regular component of most brands of cough syrup) to treat a number of types of cancer including prostate, lung and probably any other type of cancer in which a constant blood supply is required (most fortunately do); unfortunately (not unlike the Ministry of Health here in Kuwait) nobody really knows how Noscapine makes the tumours smaller. Still it does provide hope for the future and lets face it most of us didn’t know that the codeine is cough syrup was getting us high when we first took it at the tender age of four ……
* Codeine is a very mild sedative ….. it’s the stuff in NightNurse in small doses and a couple of shots of vodka in higher ones. Too bad it’s more addictive than heroin)
We’ll scream at you, give you the wrong meds and maybe even beat you to a pulp ….. but we’ll never rape ya …..
Apologies everyone, I’ve been taking a little break from everything. You see after the erm …. “incident” I’ve decided to strom out of work and have spent the past couple of days watching weeds and playing Gears of War 2 while catching up with my reading ……. Anyway here’s another morbidly distrubing post for all of you to enjoy …….
Our noble profession has recently sunk to a new low and surprisingly this hasn’t been as a result of the hard work (or lack there of) of my collegues here in Kuwait. For the first time in a long time I’ve found another healthcare provider to gripe about, another set of administrators, doctors and ward attendants to prove how dumb/bad/just plain wrong (in the Hannibal Lecter sense) doctors/nurses are.
The british healthcare system (the NHS) was once known for being robust, reliable and efficient, during the 80′s however it did go into s slump (Thatcher blamed the immigrants for the most part) and since then has gone on to try and rectify things.
For the most part they have improved remarkably over the past 2 decades, GP’s actually diagnose people, surgeons try their best to look out for their patients interest rather than just slice and dice and emergencies are dealt with within minutes rather than the 8+ hours US medicare and Medicaid is now famous for and the complete lack of urgency our boys seem to practice like a goddamn national sport.
However as with any corpration, group of people or football soccer football soccer team there’s always the one person who ends up fucking a sheep and giving everybody else a bad name (for boxing it was Mike Tyson, for us it was Bin Laden and his crew and in the case of the music industry it was Britney Spears) and the NHS is no exception.
Over the past few months over 30 different cases of sexual assault on patients have been reported and although they were initially isolated to psychiatric centers (and were therefor ignored by the higher ups) they have recently also been reported on general medical wards. The worst part is that it seems to be happening to patients who are heavily sedated or too sick to do anything about it and the person(s) involed were for the most part fired and set free without enduring any legal penalties, this was mostly because there wasn’t enough evidence to convict them (the smart bastards)
So the next time you find yourself pissed of with that MRI appointment booked for next year or that fucked up nurse that bruised you while taking your blood just remember thing could be worse …….
Like Fruit Picking only Different …..
You’ve gotta love childbirth no matter how you go about it (c-section, vaginal delivery …… and anything else they’ll come up with) the damn thing is still more painful than watching a Sly Stallone marathon …….
(Yes the pateint is awake during the video)*
(Not really a post so much as something I had to share ….. apologies …..)
*She is sedated however …. with either local or spinal anesthesia …..
It all started with a bang …..
I love plastic surgery, the idea of being able to fix the funny looking while lining your deep pockets with cash has always been a dream of mine (and pretty much everybody else’s). You get to do fairly interesting procedures on a regular basis and don’t ever have to tell somebody they’ll die(unless you deal with burns and skin cancers, or are a bad surgeon who happens to kill alot of people from time to time).
But it’s hard to believe that an industry which services the superficial and banal (for the most part) was forged in the embers of war* and is not as sexy as Nip/Tuck makes it out to be ……
It began in world war one when Queens Hospital, London was established (1917), it housed a 1,000 beds and was home to many of the young soldiers who were injured during the war, they would arrive there for further treatment after they had been brought back to the U.K.
Among the doctors who worked there was Sir Harold Gillies, hailing from New Zealand and formally trained as an ear,nose and throat surgeon, Gillies had decided to put his skills to the test and attempted to develop techniques for the treatment of facial injuries which had occurred as a result of war and friendly fire.
His first patient was Gunnery Sergeant Walter Yeo who had lost his eye lids in an accident with a cannon. Gillies performed what is now known as a pedicular flap where skin from a healthy part of the body is moved over to a raw area and refashioned to look as if nothing ever happened (well almost…. bear in mind this was 1917 ….. we didn’t even have brufen back then …..)
Not bad for something that was essentially beta testing on live humans.
Gillies and his colleagues went on to perform over 11,000 procedures on 5,000 men while at Queens and subsequently performed many other “firsts” including the first male to female sex change (1941) and male to female one in ’56.
Another set of flaps, the wax model (left) illustrates the graft (now called a flap I believe) that was performed (right)
The thing that strikes me the most about the history of modern plastic surgery is that none of it would have been possible given the ethical (not to mention social) dilemmas things like playing around with a live human or their nasty bits brings to mind these days……..
Perhaps we should just go back to experimenting on humans and skip the animals lord knows some of them do deserve it ……..
* that was a lie I think, the first Rhinoplasty (nose job) was performed in ancient India, but the story is far more interesting this way …….
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